Free Case

Doctor Information

Mark Adams, age 31

Past medical history:

Shoulder dislocation 2007

Medication:

No regular medication

Allergies:

Nill

Patient Information

Mark Adams, age 31

Presenting complaint:Pain in your knee

Open History:You have pain in your left knee that started last week and seems to be getting worse. You have been taking paracetamol and ibuprofen every day but it doesn't touch it. It started last thursday - you play badminton with a local team after work. (You play mixed doubles) You have a very big tournament final coming up. Your team are inline to get into the medals this year, you only have 2 more games to play.

If asked only:During your match, your team mate collided with you and you both fell heavily. You felt your knee twist during the fall and afterwards knee was painful however you kept playing. Once you got home you noticed the knee was not swollen, however by the next day it was twice its size and painful! Within 3 days the swelling subsided, so you initially thought it was a sprain so you've been carrying on with life as normal. However over the last few days it has started to swell again despite resting from playing badminton. You feel this is unusual, so wanted it checked, as you need it to get better by the badminton semi-finals in 3 weeks.

Your knee hasn't locked, but you almost went over again a couple of times at work as it felt like it was going to ‘go’ again. You cant see any skin changes. The swelling fluctuates with time

Past History:You have had badminton injuries previously - the only time you came to see a doctor was a few years ago when your shoulder dislocated after a particularly violent return smash. At that time you went to A+E and you had it ‘popped back’.

No regular medication or known allergies

Social history:You work as an estate agent which means you are always on your feet or in the car showing people properties. This week has been really hard with the pain. You play badminton every thursday night, you would never give this up, it is your only real hobby. Also as mentioned above you have a tournament final coming up and your team is doing really well this year. You live alone, your girlfriend works in manchester but comes up on weekends. You are a social smoker and drinker, nothing excessive.

Ideas:You thought it was a sprain but as it is getting worse, you are worried it is something more serious

Concerns:You are not bothered if you have to have a bit of time off work, but stopping badminton is not an option for you, despite what the doctor suggests.

Expectations: Stronger painkillers, and an X-ray to make sure you haven't broken the knee.

Response to Doctor:If you are told that you may have a meniscal tear, you will want to see a specialist immediately to get it "sorted". you will not want to stop playing badminton. If you are informed that even if you did have an operation, you still wouldn't be able to play in in a few weeks, and the doctor is empathetic to your situation, then you will agree to stop playing badminton for a little while.If you are offered physio, you will want to know how long it will be under the NHS. If a time of two weeks or more is given, you will get annoyed and enquire as to whether there is any other option available to you. If a private physio option is offered, you would prefer that, due to the shorter waiting list.

Examination Findings

Make the doctor examine you in this station, don't just give them the information.Cases with musculoskeletal problems make ideal situations to test the candidates examination skills, so make sure you are slick at your MSK examinations.

Systemic

Apyrexial

Left Knee

mild effusion, tender around joint line

No ligament laxity.

Unable to extend fully.

Normal sensation and power in leg

Neurovascular status intact.

If the doctor tries to do a McMurray's test, then it will be painful, same with the Apley Grind test.

If they ask you to do a duck-squat walk, it will be painful.

Mark scheme

Data Gathering

Positive

Clarifies the problem & nature of decision required

Gathers information from history taking, examination and investigation in a systematic and efficient manner.

Is appropriately selective in the choice of enquiries, examinations & investigations

Negative

Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed Unable to construct a problem list and prioritise Unable to enhance patient’s health perceptions and coping strategies.

Inter Personal Skills

Positive

Explores patient’s agenda, health beliefs & preferences.

Appears alert to verbal and non-verbal cues.

Explores the impact of the illness on the patient's life

Elicits psychological & social information to place the patient’s problem in context

Works in partnership, finding common ground to develop a shared management plan

Shows responsiveness to the patient's preferences, feelings and expectations

Provides explanations that are relevant and understandable to the patient

Responds to needs & concerns with interest & understanding

Has a positive attitude when dealing with problems, admits mistakes & shows commitment to improvement.

Acts in an open, non-judgmental manner

Is cooperative & inclusive in approach

Conducts examinations with sensitivity for the patient's feelings, seeking consent where appropriate

Is empathetic towards the predicament the patient is in with regards to his badminton.

Works with the patient to find a solution.

Avoids the use of Medical Jargon.

Negative

Does not inquire sufficiently about the patient’s perspective / health understanding.

Pays insufficient attention to the patient's verbal and nonverbal communication.

Fails to explore how the patient's life is affected by the problem.

Does not appreciate the impact of the patient's psychosocial context

Instructs the patient rather than seeking common ground

Uses a rigid approach to consulting that fails to be sufficiently responsive to the patient's contribution

When conducting examinations, appears unprofessional and at risk of hurting or embarrassing the patient

Management

Explanation:I suspect you have damaged a part of your knee called the meniscus. It acts like a shock absorber, and can be damaged after an injury to the knee. It often causes pain and swelling of the knee, and can take several months to fully heal. I can give you some treatment and some advice to improve your symptoms.

Take a good history of injury to understand the mechanism of damage to the knee:

Anterior blows directly to the knee can result in posterior cruciate ligament injury

Sideways blows can damage the medial or lateral collateral ligaments

A twisting injury can damage the menisci

Sudden deceleration or stopping can cause injury to the anterior cruciate ligament

Locking, popping and giving way are all symptoms that suggest meniscal injury

Often the pain from a meniscal injury is easily localised by the patient, and can give you a clue as to whether its the lateral or medial meniscus that has been damaged.

Swelling can give an indication about the nature of the injury, if it's within 2 hours then it's more likely to suggest a fracture or tendon/ligament rupture (as these are highly vascularised structures). Slower onset or recurring swelling, is more suggestive of meniscal injury.

Remember that in young people the meniscus is a very strong structure, and needs a good deal of force to damage it- such as skiing / sports accident. However as the knee ages, the meniscus thins, and consequently the amount of force needed to damage it diminishes.

NICE CKS now no longer recommended the McMurrays test, due to its poor sensitivity (55%) and specificity (77%) [1], and the associate risk that it may worsen small tears. However that is disputed by many surgeons, who feel the knee is well supported during a McMurrays test and therefore the risk to the meniscus is minimal. The Apley grind test however should be avoided, due to the increased loading it requires compared to the Mcmurrays test. As it happens, there is more than enough information to make an accurate diagnosis in this case without having to do the McMurrays / Apley test.

Management for a meniscal injury:Rest for initial 48 hours, apply ice and compression bandage if available. Elevate leg whenever possible. Offer simple analgesia such as paracetamol/ibuprofen. Smaller tears often do heal themselves if given time and appropriate exercises. The following provides a rough outline to management:

If there is any locking = urgent referral is required

If no locking = refer to physiotherapy

If no improvement after 6 weeks of physio then refer routinely to orthopaedics

However it is important to be guided by the patient, in this case, given he is very active and would like to keep it that way, a referral to sports physio on more urgent basis would not be unreasonable (or even the possibility of private physiotherapy as he may be seen sooner). If you have open access to MRI knee, then that is also a possibility (this may vary depending on local cirteria). As for a referral to see a specialist, it might be appropriate later on if physiotherapy doesn't resolve matters but initially conservative management should probably be tried. It is important in this case to manage the patient's expectations; whether he goes to see a specialist or not, it is unlikely that he will be able to play competitively in a few weeks time.